The Ailing Health of a Growing Nation

JODHPUR, India—Mohammad Arif visited his wife, Ruksana, in the labor ward of Umaid Hospital here on Feb. 13. She was to have a cesarean-section the next day. It would be her first child.

"You're going to deliver on Valentine's Day," Mr. Arif told his wife.

"Everything will be fine, with God's will," she said.

Hospital Needs Lifeline

Instead, the young family fell victim to the dysfunction plaguing India's public-health system, an overstretched and underfunded patchwork on which the vast majority of India's 1.2 billion people rely.

On Valentine's Day, 20-year-old Ms. Ruksana gave birth to a baby girl. But the young mother's bleeding couldn't be stopped. Umaid Hospital was about to descend into crisis: Up and down the maternity ward, new mothers were mysteriously starting to die.

India supplies doctors to hospitals the world over. Within India itself, a thriving private health-care industry—serving a growing middle class and the wealthy—is a byproduct of the nation's economic ascendancy. By some important measures, India's health is improving: Over two decades, life expectancy has risen to 64 years in 2008 from 58 in 1991. Infant mortality has declined as well.

Poor families in India who can't afford private hospitals must rely on the severely underfund public health system, often with disastrous results. WSJ's Pracheta Sharma reports from Calcutta.

Yet maternal and infant health remains an area where India particularly lags behind. Last month in the state of Bihar, 49 children died from an unidentified viral infection over a few weeks in three districts. A month ago at a hospital in the city of Kolkata, 22 babies died in four days.

Overall, the nation's vast, government-run health system can be a dangerous place. Hospitals are decades out of date, short-staffed and filthy. Patients frequently sleep two to a bed. The Indian government invests only 1% of gross domestic product in health care, according to the Organization for Economic Cooperation and Development. Only seven countries spend less.

The nation faces a health crisis on two fronts, experts say. Not only has it failed to solve developing-world health problems such as high infant mortality and malaria, but now it also faces a sharp rise in rich-country health problems, such as diabetes. India has 50 million diabetics, the most of any country, as diets and lifestyles have changed amid rising prosperity.

Efforts to improve maternal health are having unintended consequences. In 2005 India started paying women $30 to have their babies in hospitals instead of at home. Partly as a result, last year hospitals performed 17 million deliveries, up from just 750,000 in 2006. Many hospitals simply can't handle the traffic, government and hospital officials say.

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Overall, India's central government set a goal in 2005 of doubling national health-care expenditures to 2% of GDP. It has fallen far short of that, officials say, partly because of the need to improve other social programs, such as education.

"We have so many competing social priorities," says Anuradha Gupta, a senior official at the health ministry who works on maternal and child issues.

Umaid Hospital, constructed in 1937 in an Art Deco style, stands in the heart of Jodhpur, a historic fortress-city of 1.4 million in the western state of Rajasthan, one of India's poorest. Funded by the government, Umaid provides care to the poor and specializes in women and children.

The hospital performs 20,000 deliveries a year—about one every 30 minutes—a more-than-tripling since 2003, says Superintendent Narendra Chhangani. Most births occur in a labor room barely changed in some three-quarters of a century. The hospital's 400 obstetrics beds are served by 15 gynecologists, Dr. Chhangani says, half the number needed.

ENLARGE

Nurses and a cat at North 24 Parganas District Hospital, where one pediatrician sees about 500 kids a day.
The Wall Street Journal

Recruiting new doctors is tough, Dr. Chhangani says, because the pay is low and conditions are poor. Patients' families sleep on floors and in a courtyard next to the labor wards. The smell of urine hangs in the corridors. Wobbly ceiling fans stir the air.

In February, a government survey of the hospital found that needles weren't always disinfected and noted an incident of a rat bite in the nursery. Dr. Chhangani says the report exaggerated the hospital's hygiene problems and didn't reflect the practical realities of an urban Indian hospital.

Those realities can create an environment ripe for the kind of disaster that struck in February, just as Mr. Arif arrived with his pregnant wife, Ms. Ruksana. She checked in to Umaid on Feb. 4.

Ms. Ruksana, 5-foot-2-inches, was herself born in the countryside outside Jodhpur. She completed the fifth grade before her father pulled her out of school to help with chores.

When she was 15, she had an arranged marriage with Mr. Arif but didn't move in with him for another two years because she was so young. The day Ms. Ruksana found out she was pregnant last year, she and Mr. Arif went to celebrate at a fair with folk singers and food stalls, enjoying a fast-food dish of buttered bread and thick vegetable curry.

It was probably a bit of a splurge. Their household of seven, including an extended family of relatives, earns a total of less than $100 a month dyeing and ironing scarves and bedsheets from a nearby factory.

At Umaid Hospital, doctors decided Ms. Ruksana, partly because of her size, should have a C-section. She delivered her baby girl on the afternoon of Feb. 14. Her name: Mehek, which means "fragrance."

Q&A

On Monday, Aug. 1, Amol Sharma, Geeta Anand, Megha Bahree and Krishna Pokharel — the reporters who worked on this story — will be answering your questions about India's public health crisis. Tweet @wsjindia with the hashtag #FlawedMiracle or email your questions to indiarealtime@wsj.com. They'll blog the answers between 4 and 7pm IST, 6:30 and 9:30 am EST on blogs.wsj.com/indiarealtime

Ms. Ruksana left the operating room in high spirits. But late that night, she noticed the dressing over the stitches was wet.

She was bleeding at the site of her wound. It got worse overnight. The doctors on duty couldn't stop the blood.

The next morning, Dr. Desai, a senior gynecologist at Umaid, came to see Ms. Ruksana. Her blood was taking 10 times longer than normal to clot. Her arms showed green patches, indicating heavy internal bleeding.

Dr. Desai was already having a busy week, as usual. Her team of four gynecologists routinely sees 350 patients per week. Interrupting her examination of Ms. Ruksana, she raced to a nearby ward to tend to a woman stricken with jaundice whose dead fetus needed to be surgically removed.

Dr. Desai, who has two decades' experience, couldn't explain Ms. Ruksana's condition. But the doctor says she had a sinking feeling. In the previous two days alone, four women at Umaid had died from uncontrollable postpartum bleeding. Typically, the hospital averaged five or six maternal deaths per month. Dr. Desai called in other gynecologists and the region's top internal medicine specialist.

The hospital's blood bank didn't have enough blood on hand, so Mr. Arif says doctors told him he needed to come up with 10 vials for his wife's transfusions. He raced to round up relatives and friends to give blood.

How India Stacks Up

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Late that afternoon, Ms. Ruksana transferred to Mahatma Gandhi Hospital, another government institution in Jodhpur that handles critical cases. Dr. Desai searched online for clues to the problem. She phoned obstetricians as far away as Boston. "I was traumatized, I was losing confidence," Dr. Desai says.

The next day, Feb. 16, more patients emerged with uncontrollable bleeding, and two died.

Dr. Chhangani, the hospital's superintendent, says that up to that point his gynecologists had been telling him they believed the deaths were due to ordinary complications. But by Feb. 16, he says, he was anxious. He called his superior, Dr. R.K. Aseri, the principal of nearby Dr. S.N. Medical College, which oversees the local public hospitals.

Dr. Aseri assembled a group of local specialists. After a 3½-hour meeting, they decided that all drugs used in deliveries should be swapped out in case they were infected.

That evening, Dr. Chhangani and Dr. Aseri visited Umaid's operating room and labor room and made an impassioned plea to the staff for proper hygiene. "You should always put on your mask and change your shoes when you enter the operating theater," Dr. Chhangani says he told hospital staff. "Don't allow anyone in who shouldn't be there."

Some doctors suggested shutting down the operating rooms until the mystery was solved. Dr. Desai said in a recent interview that such a move simply wasn't realistic. "There are so many poor patients here. They can't afford to go anywhere else."

The next few days, more patients died and still more fell ill. Ms. Ruksana was now one of three of Dr. Desai's patients suffering from mysterious, severe postoperative complications. Dr. Desai gave Mr. Arif a grim update one afternoon. "Her condition is very critical. We're failing to understand why we can't stop the bleeding."

ENLARGE

Moksuda Siddiki learns of the death of her baby—one of 22 to die at a Kolkata hospital in just four days.
The Wall Street Journal

The crisis depleted the hospital's already low supplies of surgical caps, face masks and other basic gear. So hospital staffers told the relatives of critically ill patients to go buy their own.

Families were instructed to bring back gloves, syringes, catheters, an abdominal drain and other items, according to a survey by a human-rights group, the People's Union for Civil Liberties, and health-care activists. Some families said they spent anywhere from a few hundred dollars to several thousand dollars of their own money on the supplies, according to the report.

Dr. Chhangani calls it an "exaggeration" that families had to buy their own medical supplies.

As the crisis escalated, tempers flared. Family members roamed the corridors, shouting at doctors and demanding explanations for why their loved ones were dying and why they were being asked to provide their own blood and hospital supplies.

At the Mahatma Gandhi Hospital intensive-care unit, Ms. Ruksana suffered kidney failure and septic shock. But she was hanging on.

Dr. Chhangani, Umaid's superintendent, increasingly focused on the possibility of contaminated medications. On Feb. 22—seven days after Ms. Ruksana first began bleeding uncontrollably—a lab technician reported finding contamination in bottles of saline solution administered intravenously after blood loss or surgery. The fluid was infected with bacteria that produce lethal endotoxins, chemicals that can cause multiple organ failure.

The finding was too late for Ms. Ruksana. That day, she died.

Over the course of a month, she and 15 other new mothers died at Umaid Hospital. Two gravely ill women survived.

Mr. Arif and his relatives pooled $10 to hire a car to take her body home. They held a funeral that afternoon, attended by about 100 family and friends.

Dr. Desai, who says she had been suffering nightmares about Ms. Ruksana and her other patients, spoke to Mr. Arif the day of the funeral. Mr. Arif tried to soothe her. "Whatever had to happen has happened. It was God's will. Don't cry," he says he told the doctor.

For Mr. Arif, raising Mehek without her mother hasn't been easy. He has been getting help from his sister and from Ms. Ruksana's family. One afternoon in July, he made the 65-mile journey from Jodhpur to Ms. Ruksana's hometown, where Mehek had been staying with the in-laws for a few days. Ms. Ruksana's parents and their 10 children share a small house with two bedrooms and one bathroom with a coconut-size sink.

On a scorching afternoon, family gathered in the living room to play with Mehek, now five months old, sporting a small dot on her eyebrow to ward off evil spirits. Ms. Ruksana's mother, Jareena Bano, looking down at Mehek in her lap, says simply, "She's our Ruksana now."

There was plenty of blame to go around in Umaid Hospital's wave of deaths. India's Central Drugs Laboratory, a government facility in the city of Kolkata, determined that the IV fluid, made by Parenteral Surgicals Ltd. of Indore, was contaminated with dangerous bacteria.

Authorities arrested a quality-control official at Parenteral, Sanjay Shah, on charges of conspiracy, poisoning and violations of India's Drugs and Cosmetics Act of 1940. He is in jail pending trial. His lawyer, Mahendra Singhvi, declined to comment.

In a statement, Parenteral's director, Manoj Khandelwal, blamed the hospital, saying poor storage of the IV bottles at Umaid Hospital was the likely cause of the contamination. He also said there was no concrete evidence that the IV fluids caused the deaths.

Dr. Chhangani denies the hospital erred in storage. He says a shipment of 4,000 IV bottles from Parenteral arrived in early February and the fluids were so badly needed that they weren't stored before being distributed to labor wards.

A state government investigation into the Jodhpur deaths blamed the hospital staff for lax procurement of medicines. One issue identified by the investigators: Parenteral wasn't on the hospital's list of approved IV vendors, but when a supplier shipped Parenteral products, the hospital didn't catch the error.

Umaid's head of gynecology and the employees running the hospital's drug store have been suspended indefinitely. A separate report by the central health ministry accused Umaid officials of "callousness" for moving too slowly to investigate the deaths.

In recent months, at least two hospitals in the same state, Rajasthan, said they found fungus contamination in bottles of IV fluids made by other manufacturers.

Officials in two other states also recently seized contaminated IV fluid from hospitals. In one case, patients themselves noticed a fungus growing in the IVs and alerted officials. There were no deaths; the problems were apparently caught early enough.

Dr. Chhangani is now spending more than $500,000 in state funds on renovations that will, among other things, double the Umaid labor ward's capacity to 80 beds, create a proper waiting room and coat the walls with antibacterial paint.

One afternoon earlier this year, a government official paid a visit to Mr. Arif's house. He had come to deliver the standard government payment to close the matter of the death of his wife, Ms. Ruksana: a check for 500,000 rupees, or about $11,000.

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